22 MASON STREET - BUILDING JACKET 2Z /vtRSoitP Ste^
74520 4046 M
Certificate No: 358-11 Building Permit No.: 358-11
Commonwealth of Massachusetts
City of Salem
Building Electrical Mechanical Permits
I
This is to Certify that the RESIDENCE located at
Dwelling Type
22 MASON STREET in the CITY OF SALEM
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Address Town/Cit Name
IS HEREBY GRANTED A PERMANENT CERTIFICATE OF
OCCUPANCY
OCCUPANCY PERMIT FOR(22 MASON STREET)
I
This permit is granted in conformity with the Statutes and ordinances relating thereto, and
expires ----
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_ unless sooner suspended or revoked.
Expiration Date
Issued On:Thu Oct 21,2010 "
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22 MASON STREET_ 358-11
i �s # — COMMONWEALTIT OF MASSACHUSETTS
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Map 26
iBlock i O
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_. -- - CITY F SALEM
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(Lot _0309
CategoryREPAIR/REPLACE 7
ipertntt# 3581 _ BUILDING PERMIT
Project# — JS-2011_-00035,4
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jEst. Cost: $13,00_0.00
(Fee Charged:—' $0:00
1Balance Due._ _S—.0 0 PERMISSION IS HEREBY GRANTED TO:
(Const Class. _
Contractor: License: Expires
IfUse Group _ MEDIA CONSTRUCTION STATE(-062118
'Lo'
Stze
U (5075 175_6
Zoning R2 - ' Owner: KHAN KATHERINE
Units Gamed: Applicant: MEDIA CONSTRUCTION
Units Lost SAT: 22 MASON STREET
(Dig Safe#:
ISSUED ON: 21-Oct-2010 AMENDED ON: 1 EXPIRES ON: 21-Mar-201 I
TO PERFORM THE FOLLOWING WORK:
REMODELING KITCHEN DUE TO FIRE DAMAGEibll
POST THIS CARD SO IT IS VISIBLE FROM,THE STREET
Electric Gas Plumbin¢ Buildine
lindergrmmd: Underground: Underground: Excavation:
I
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chinmcy:
D.P.W. Fire Health
.Meter: Oil: Insulation:
Filial:
House At Smoke:
Water: Alarm: Assessor Treasury: -
Sewer: Sprinklers: Final:
I
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON(VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Fee Type: Receipt No: Date Paid! Signatu -% 'IC !heck No: Amount:
BUILDING pe Aa REC-2011-000449 21-Oct-10 760 50.00
�aaou$e� �R h a .xl tl ,M t3 Occupy
1�iol �ee� � �k Y ai tit' l"y
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The Commonwealth of Massachusetts
Board of BuilJing Regulations and Standards CITY
•y► Massachusetts State Building Code, 780 CMR, 7o'edition OF SALEM
Revised Jmrnrvr
lluilding Permit Application To Construct, Repair, Renovate Or Demolish a /. _INAY
One-or rivo-Fomily Dwelling
This Secodijfor Official Use Only
Building Permit Num qj1p Applied:
Signature: J/ / / f/
Building Cwnmissionedl for of gs fate
SftTION 1:SITE INFORMATION
1.2 Assessors Map& Parcel Numbers Numbe
®%
I.la Is this an accepted street?yes no Map Number Parcel Number
I Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area fsq 11) Frontage(11)
1.5 Building Setbacks(R) _
Front Yard Site Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publi Private O Zone: _ Outside Flood Zone?Check if e MurticipawOn site disposal system O
SECTI01412: PROPERTY OWNERSHIP'
2.1/ nert of Record
,:Z2e0 �J
Name(Print) Address for Service:
SignWurc Telephone
((( SECTION JI: DESCRIPTION Of PROPOSED WORK'(check all that apply)
New Construction O Existing Building Owner-Occupied Repairs(s) Alteration(s) O Addition O
Demolition O Accessory Bldg. Number of Units_ Othe O Specify:
Brief Descriptio of Propo rk':
i
c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials
I. Building S Building Permit Fee:S Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical S O Total Project Cosh(Item 6)x multiplier x
). Plumbing Is 2. Other Fees: S
4. Mechanical (IIVAC) S List:
S. Mechanical (Fire S
Su ression Total All Fen:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL)
3,T."'ar r�Y� � I.iccnse Number livpimtion T.rm
Name .CSL•1lulder I.ist CSL Type Ism below) ( f
A f 11escri ion
N
i "'1 U unrestricted(up to 35,000 Cu. Ft.
R I Restricted IR2 Family Dwelling
Si to M Masomy only
RC I Residential Rooting Covering
Nlephs WS Residential Window and Siding
SF Raidial Solid Fuel gurninst Appliance Installation
D RaiJcmntial Demolition
5.2 Registered Home I proven, t Contracto (HIC)
C
I IIC Company Nam Registnuion Number
e a HI Regisl t ame
AJJ
7� SO _ Espiration Date
Signature 'ttlephorte
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. / 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached?, Yes......... No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorizes �M1 r to act on my behalf,in all marten
relative to workp rized by this building permit application.
Si ureofOwner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, 9- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print(1 name
Signature of Owner or Authorized Agent Date
Si under the sins penalties of 'u
NOTES:
1. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.R7,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"may be substituted lbr"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I w::a:1'Y UNISt IC III
I]1'oft I20 WASHING ION S'I aELT * SAL E.M.M.vsS NO It %I'IS 01970
11a.:978-743-9595 • f.sx: 978.74VIN46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
� ) flicant Information Please Print Le ihly
Nalnd lnusincsslOr,�,anintinNlnJtvlduuq: /�j'�
Address: may'
City'Srttc;/sip- � , Phone
Are vuu an employer'.' Check the appropriale box: "Type of project(required):
4. ❑ I inn a g ❑eneral contractor and I 4. New construction
e,�..,�p
I all,o employer with- _
en,pluyces(full ai,tUur part-time).' have hired the sub-contractors g
2.❑ I :un a sole proprietor or partner-
listed on the attached sheet. �• �emodelin
ship and have no cmph)yuus These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9- [:] Building addition No worriers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.]- officers have exercised their
right of exemption per MGL 1 I.❑ Plumbing repairs or additions
3.❑ I ant a homeowner doing all work c s152, c 1(4),end •have no
myself. (No workers' comp. � 12.❑ Rouf repairs
insurance required.] employees. LNo workers' 13.0 Other
comp. insurance required.]
•;Soy:glphcaul thut chucks box 01 must:dsu till mn rho section bwauw showing(heir workas'cuntpcnsution policy inlor,natiun.
' I lumwwners who submil this affidavit indicating they are doing all work and then hire outside coniraefon musi buhmil a new al'na.n it indiunng such.
:(' oust"that check this box meal auxhed an additional.heel shuwiny the name of the sub•aontracturs and their workers'comp.policy informatiun.
/nor an employer that is providing workers'c•umpen.cndor insuranee fur uty employees. Below Is the policy and job site
iufurrnution. 0 ?� , J,, }(', /
Insurance Company Name:— y� / -f{-y�p�-✓GV
Policy y or Scif-ins. Lic. Expiration D;:
n: � - ----
Job Site Address: A 5n, �� CityiStatc/Zip: '
Attach a copy of the workers' compensation policy declaration pulse (showing;the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.%-IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a Jay against the violator. lic advised that a copy of this stutcment may be forwarded to the Office of
Inrcangauons of the DIA for insurance coverage vtrilicuion.
I do hereby certify Ire t pI its mid penalties of perjury that the information provided above is true and correct.
Si,,:l,uure: - Date,
Phllre;i: �� O-DYJ
Official use only. Do not write in this area,to be completed by city or four afjic•ia/.
City or 1'mwn: Permit/l.gcense
Issuing Aulhurity (circle one): i
1. Board of llealth 2. Building Dcpartmcut 3. Cilyi fown Clerk J. Electrical Inspector 5. Plumbing Inspector
G. Other _--
Contact l'crwu: _.. . .__. Phone 1:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or tither legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an Individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance w ith the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s) name(s), address(es)and phone nutuber(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and dute the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Seif-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations lias to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicetse applications in any given year,need only submit one affidavit indicating current
policy information of necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by(he city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The 0I-- c bt Investigations would like to thank you in advance fur your cooperation and should you have:my questions,
please du not hesitate to give us a call.
the Dcp:rtinent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itcvixd 5-26-05
Fax #617-727-7749
www,mass.gov/dia
l CI Y vl- JNLLNIL
PUBLIC PROPRERTY
DEPAR"I'MENT
Construction Debris Disposal Affidavit
(rcrluired iur all demolition and renovation work)
In accordance rill, the sixth edition ofthc Slate Building Code, 780 CNIR section I 1 L5
Dcbris, and the provisions of MGL c 40, S 54;
Building P Bermit is issued with tits condition that the debris resultin0 Isom
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
t l t. S 150A.
The debris will be transported by:
Inarnc of harder) "
I he debris will be disposed of in :
INco' �y���jf
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,,,I yr,r"t),;, CITY OF SALEM, MASSACHUSETTS
':`,..0 BUILDING DEPARTMENT
- . ,/ 120 WASHINGTON STREET,3'FLOOR
4=C7 yJ
TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
November 5, 2019
Katherine Khan
22 Mason Street
Salem Ma. 01970
Chimney—Building code violation.
Dear Ms. Khan,
I was notified by your abutter that bricks from your chimney fell into their property. Yesterday, I visited your
property and observed the rear chimney with leaning and with several bricks missing. This represents a danger
to life and limb and must be dealt with immediately. Short term, the area below the chimney needs to be
cordoned off and a qualified mason must repair the chimney as soon as possible.
The violation is Massachusetts State Building Code ninth edition 780 CMR section R102.8. If you feel you are
aggrieved by this order, your Appeal is to the Board of Buildings ,Regulations and Standards in Boston.
Failure to address this issue will result in Municipal code tickets and further enforcement actions.
If you have any questions,please contact this office directly.
Sip1c�erely
(
Thomas St.Pierre